Get Oh Odm 10193 2019-2026

The OH ODM 10193 form is essential for individuals seeking assistance from the Ohio Department of Medicaid through a qualified income trust verification. This guide provides clear, step-by-step instructions on how to accurately complete this form online.

Follow the steps to complete the OH ODM 10193 form effectively.

1. Click the ‘Get Form’ button to retrieve the OH ODM 10193 form and open it for editing.
2. Enter the individual's information in the designated fields. Fill in the individual's full name, date of birth in the mm/dd/yyyy format, Medicaid ID number (12 digits), and case number. Additionally, ensure you include the individual’s street address, apartment or unit number (if applicable), city, and zip code.
3. Proceed to the trust information section. Input the name of the trustee, their county, and the date the trust was established (mm/dd/yyyy). Provide the name and address of the location where the trust account was established, including street address, city, state, and zip code.
4. In the account information section, provide the account name, account number, the name of the account contact, and their phone number.
5. Select the sources of income that apply by checking the relevant boxes. Provide amounts for each source, including Social Security, company retirement, veteran benefits, or any other specified sources. Indicate the amount to be deposited into the trust effective from the specified date.
6. Specify the monthly account maintenance fee. Ensure this value reflects the approved amount, as higher fees may require additional actions.
7. The trustee must then provide their signature and the date (mm/dd/yyyy) to authenticate the form.
8. After completing all sections, save the changes made to the form and prepare to submit it.
9. Submit the completed document to your local county department of job and family services (CDJFS). Refer to the provided directory link for contact information, or if applicable, send the form to the designated Medicaid eligibility email for exceptions.

Begin filling out the OH ODM 10193 form online now to ensure a smooth process!